The Against Malaria Foundation (AMF) was one of our top-rated organizations from 2009 to 2013 and has received over $10.6 million due to GiveWell's recommendation. In late 2013, we removed AMF from our top-rated list because we felt it had limited room for more funding (more).

Published: November 2012; Updated: November 2013

Summary

What do they do? AMF provides funding for long-lasting insecticide-treated net distributions (for protection against malaria) in developing countries.

Does it work? There is strong evidence that distributing nets reduces child mortality and malaria cases. AMF has relatively strong reporting requirements for its distribution partners and provides a level of public disclosure and tracking of distributions that we have not seen from any other net distribution charity.

What do you get for your dollar? We estimate that it costs $5.80-$6.15 per net distributed by AMF. The numbers of malaria cases prevented and lives saved are a function of a number of difficult to estimate factors, which we discuss in detail below.

Room for more funds? AMF has struggled to come to agreements with countries for net distributions. As of November 2013, it has spent only a small portion of the funds it received in the previous two years. We do not plan to recommend more donations to AMF until and unless it commits the bulk of its current funds to net distributions.

Our review process

We began reviewing AMF in 2009. Our review has consisted of:

  • Reviewing AMF's public records for each of its net distributions and other documents AMF has shared with us.
  • Extensive communication, including several meetings at AMF's London headquarters with AMF Founder Rob Mather, to discuss AMF's methods and funding needs.
  • A visit to AMF's distribution partner organization, Concern Universal, in Malawi in October 2011 (notes and photos from this visit).
  • Reviewing materials from AMF’s distribution in Malawi in early 2012 (conducted by Concern Universal), including pre-distribution registration data, distribution reports, and data from a 6-month post-distribution follow up survey. We have also communicated with Concern Universal’s Malawi Director, Robin Todd.
  • Conversations with Peter Sherratt, a member of AMF's Board of Trustees; Don de Savigny, a member of AMF's Malaria Advisory Group, and other individuals (who requested to remain anonymous) familiar with AMF's work and its attempts to finalize distributions over the past two years in Togo, Mali, Nigeria, Senegal and Sierra Leone.


All content on Against Malaria Foundation, including past reviews, updates, blog posts and conversation notes, is available here.

A few key terms for this review

  • A net refers to any bednet intended to block mosquitoes, whether treated with insecticide or not.
  • An ITN is an insecticide-treated net. As discussed at our write-up on ITNs, distribution of ITNs has been rigorously studied and associated with declines in under-5 mortality and overall malaria cases.
  • A LLIN is a long-lasting insecticide-treated net, intended to serve as an effective ITN for 4-5 years (details at our write-up on ITNs). The nets distributed by AMF are LLINs,1 and (as noted in our write-up on large-scale ITN distributions) most large-scale donor-financed malaria control today utilizes LLINs.

What do they do?

AMF provides long-lasting insecticide-treated nets (for protection against malaria) in bulk to other organizations, which then distribute them in developing countries.

Prior to November 2011, AMF contributed LLINs to small-scale distributions. Since then, it has de-emphasized small-scale distributions and it expects larger-scale distributions to be the primary way in which it distributes LLINs in the future (more below).

AMF has conducted one large-scale distribution in conjunction with Concern Universal in Malawi, which took place in December 2011-March 2012. For details on the Concern Universal distribution, see our March 2012 and September 2012 updates.

Process for distributions

Selecting locations for distributions

  • When selecting locations for future distributions, AMF told us it consults a series of sources as it believes there is no one reliable resource with up-to-date information to determine where nets are needed. Sources it consults include the Alliance for Malaria Prevention's (AMP's) list of countries with significant net gaps, other malaria control funders, in-country technical advisors, the relevant National Malaria Control Program (NMCP), implementing organizations and the African Leaders Malaria Alliance.2

    In the case of its distribution in Malawi, AMF received estimates of country-level gaps from the Alliance for Malaria Prevention (AMP) and from the Malawi National Malaria Control Program (NMCP). Rob Mather, AMF's founder told us that, although AMF did not have a high level of confidence in the net gap numbers presented by the NMCP, nor those it was sent by the Global Fund, it did have a high level of confidence that the net gap was significantly higher than the 250,000 LLINs AMF was considering providing.3 Note that the materials AMF has sent us from the period prior to its decision to enter Malawi do not include quantified estimates of Malawi's LLIN gap,4 though they do make it clear that there is a gap,5 and later reports (from after AMF had decided on Malawi) show a quantified gap for the country.6

    As of November 2012, AMF was considering future distributions in seven countries (more below). A November 7 update from AMP reports LLIN gaps for all of these countries.7

  • AMF told us that it also consults other malaria control funders, implementing organizations, and the relevant National Malaria Control Program (NMCP) to verify estimates of how many additional LLINs are required to reach full coverage in a country.8 We have seen some correspondence between AMF and the NMCP in Malawi which took place prior to AMF’s decision to fund a distribution in Malawi.9 AMF also shared with us correspondence that it had with representatives of the NMCP in Togo, with regard to potential future distributions.10
  • As AMF investigates countries with existing net gaps, it also looks into organizations working within those countries that could serve as distribution partners.11 AMF's distribution partners must have the capacity and willingness to carry out a distribution that meets AMF's requirements (more below).12

    Before deciding to work with Concern Universal in Malawi, AMF requested a distribution proposal, including information on malaria risk in the distribution area (including data on reported malaria cases), other net distributions in the area, coordination with government, and how the distribution would be carried out.13 In addition to working with Concern Universal in Malawi, AMF has had discussions with Plan in Mali and Togo about potential future distributions (see our September 2012 update for further details.)

Requirements for distribution partners

In order for AMF to partner with an organization, the organization must agree to the following requirements:

  • Pre-distribution registration survey: AMF requires that its distribution partners carry out a pre-distribution registration survey (PDRS) across the entire distribution zone to establish the number of sleeping spaces and LLINs in a condition such that they have at least one year of remaining use. (In the case that such data already exist, AMF and the partner discuss whether the data is reliable and up-to-date, or whether a new PDRS should be conducted.14) In its large-scale distribution in Malawi, AMF worked with Concern Universal, which conducted a PDRS and shared the full results from the survey with us.15
  • Case rate data: AMF asks distribution partners to provide monthly malaria case rate data from all health centers in the distribution zone for 12 months preceding and 4 years following the distribution.16 Concern Universal has provided case rate data for each of the 37 health centers in its distribution area in Malawi.
  • Distribution monitoring: An additional requirement is to provide AMF with photos and videos from the distribution.17 As of November 2012, Concern Universal has provided photos and/or videos for all but 1 of the 14 “sublocations” in Malawi in which it had distributed LLINs earlier that year.18
  • Post-distribution follow-up: In the past, AMF required partners to conduct follow-up surveys at 6, 18, 30 and 42 months after the distribution, assessing net condition, what percent of nets are hung, and whether nets are being used correctly. It now requires partners to conduct follow-up surveys at 6-month intervals, and for a period of 3-4 years.19 Following the distribution in Malawi, AMF reported that Concern Universal visited 6% of households in its distribution area 6 months after the distribution.20 See our September 2012 update for further details.

AMF looks for partners who, in addition to agreeing to the above requirements, are clear and responsive in their communication with AMF.

Partners must be able to procure funds to cover all non-net costs of the distribution.21 We have expressed to AMF that we are concerned that, by requiring partners to pay for the non-net costs of the distribution, it may limit its capacity to distribute nets. AMF was receptive to the possibility of funding non-net costs in the future, if it believes that doing so would increase its ability to distribute LLINs quickly.22 AMF also told us: "a) in over six years of conducting distributions of some 1.5 million nets there has never been a problem with distribution partners securing funding for non-net costs; b) this may or may not change with larger scale distributions."23

Does it work?

On a separate page, we discuss the general evidence behind distribution of LLINs. We conclude that there is strong evidence that these distributions can be expected to reduce child mortality and malaria cases.

When evaluating the effectiveness of an LLIN distribution organization, we seek to answer the following questions:

  • Are LLINs targeted at people who do not already have them? AMF requires partners to complete pre-distribution surveys to determine the number of nets required, if reliable and recent survey data are not available. Concern Universal, AMF’s partner in Malawi, conducted and shared the full results of its pre-distribution survey. We are not fully satisfied with the pre-distribution surveys' ability to ensure that people aren't under-reporting their existing LLIN ownership in order to get more LLINs, but believe that reasonable measures are being taken to address this issue.
  • Do the LLINs reach the intended destinations? AMF requires that distribution partners post pictures and videos of LLINs being handed out. Concern Universal also posted weekly distribution reports on problems with the distribution and how it was addressing them.
  • Are LLINs targeted at areas with high rates of malaria? AMF seeks out distribution partners in countries that are known to have high rates of malaria.
  • Do those who receive the LLINs install them in their homes properly? Do they utilize them consistently over the long term? In the past, AMF required partners to conduct follow-up surveys at 6, 18, 30 and 42 months after the distribution assessing net condition, whether nets are hung, and whether nets are being used correctly. It now requires partners to conduct follow-up surveys at 6-month intervals, and for a period of up to 3-4 years. We have seen 6-month follow-up results from the large-scale distribution in Malawi which are consistent with high, proper usage of nets. We do not have longer-term data from large-scale distributions.
  • Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF? The limited evidence we have suggests the former.

Details follow.

Are LLINs targeted at people who do not already have them?

AMF requires that distribution partners conduct pre-distribution surveys (if recent, reliable survey data are not available) to determine the number of existing LLINs with at least one year of remaining use and the number of nets required in each household.24 This process includes door-to-door surveys of every household in the targeted district by government health workers, followed by village meetings in which staff of AMF's distribution partner read off household names and the number of LLINs that have been allocated to each household; households then indicate if any errors have been made. We observed one such village verification meeting during our visit to Malawi in October 2011.25

Concern Universal conducted a pre-distribution survey, and shared the full results from the survey.26 Based on GiveWell's suggestion, AMF's distribution partner also decided to send its staff to random households at this stage to spot-check the accuracy of its data.27 After the first two weeks of spot checks, the distribution partner reported that it had not found any discrepancies between the number of nets community members said they needed during the verification meeting, and the number of nets found to be needed during the subsequent household visit.28

We believe it is possible that some households may over-report the number of LLINs they need. Cases of households hiding nets in order to receive extra LLINs have been observed in universal campaigns in Senegal and Nigeria.29 That said, we believe that the steps AMF and its partners are taking to minimize the ability of community members to request more nets than they need are reasonable. We will look for the same approach in future AMF distributions, and will request details of how nets were allocated at the household level.

In Malawi, household surveys conducted by the National Malaria Control Programme (in districts not receiving AMF LLINs) have found "much larger LLIN gaps than first thought,"30 and it is not clear to us what the cause of this discrepancy is. We will seek more information when available to assess what this indicates about ensuring nets are accurately distributed and used in large-scale distributions.

Do the LLINs reach the intended destination?

AMF requires that partners send photos and videos of distributions.31 As of November 2012, Concern Universal has provided photos and/or videos for all but 1 of the 14 “sublocations” in Malawi in which it had distributed LLINs earlier that year.32 As we report in our March 2012 update, there were a number of issues that arose during Concern Universal’s distribution in Malawi, which were reported in its weekly updates during the distribution, including attempted thefts, double registrations and logistical problems.33 Overall, Concern Universal seemed to be aware of potential problems and had a system in place to address them.34

Are LLINs targeted at areas with high rates of malaria?

At the highest level, AMF appears to exclusively target countries with known malaria risk.35 In its distribution proposal for AMF, Concern Universal reported the number of malaria cases in the proposed distribution are over a twelve month period (June 2010 to July 2011).36

Do those who receive the LLINs install them in their homes properly?

In the past, AMF required partners to conduct follow-up surveys at 6, 18, 30 and 42 months after the distribution to assess net condition and whether nets are hung and used correctly. It now requires partners to conduct follow-up surveys at 6-month intervals, and for a period of 3-4 years.37 Following the distribution in Malawi, AMF reported that Concern Universal visited 6% of households in its distribution area 6 months after the distribution.38 The survey found a 90% usage rate.39 In general, surveys from mass LLIN distributions in other countries have found usage rates of 60-80%. (For more, see our page on mass LLIN distributions.)

District by district data is available on AMF's website at http://www.againstmalaria.com/SurveyForms_JobsSummary.aspx (archived). See our September 2012 update for further details.

Do those who receive the LLINs utilize them consistently over the long term?

We do not have information on long-term usage rates for LLINs distributed in large-scale AMF distributions, the first of which was conducted in December 2011-March 2012.

Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF?

For the distribution in Malawi, AMF received data from the National Malaria Control Program on population figures and LLINs already distributed by district, as well as LLINs that had been committed to the country by other funders. AMF estimated, in September 2011, that an additional 909,586 nets were needed to achieve universal coverage,40 of which AMF contributed 268,240.41

Possible negative or offsetting impact

  • Do donated nets displace government health funding? This could be a concern if government funding that otherwise would have been spent on LLINs is spent on other, less worthwhile budget items. We have little sense of how important a concern this is in AMF's case. In the case of the large-scale distribution in Malawi, all anticipated nets were expected from international donors, and the total supply appeared to be still insufficient for country-wide universal coverage.42
  • Will insecticide-treated nets continue to be effective? As discussed at our report on insecticide-treated nets, there is strong evidence for the effectiveness of this intervention, but there is a possibility that environmental changes, including changes in the size and insecticide-susceptibility of mosquito populations, could affect how well insecticide-treated nets work.
  • Do free LLIN distributions distort incentives for recipients or distort local markets for nets? As discussed at our report on insecticide-treated nets, we feel that there is a reasonably strong case for distributing LLINs freely rather than selling them at market (or even below-market) prices.
  • Could distribution of LLINs be inequitable and unfair, causing problems in the targeted communities? We feel that the process that was followed for AMF's large-scale distribution in Malawi is well-suited to ensuring that all who want LLINs receive them.
  • Does AMF divert skilled labor from other areas? Net distribution is conducted by low-level government health staff in partnership with the staff of AMF's partner NGO.43 According to AMF's partner in Malawi, government health staff are normally involved in activities such as disseminating health-related information, reporting on levels of stunting and disease, carrying out immunization campaigns, and providing nutrition support.44 We don't know the extent to which net distribution reduces their ability to complete other duties, though we note that net distributions are generally completed within a few days in each local area.

What do you get for your dollar?

Cost per LLIN distributed

The best estimate we have for the cost to purchase and distribute an LLIN is $5.80.45 To estimate the full cost to purchase and distribute an AMF LLIN, we add AMF's costs in the UK to this figure. Assuming AMF distributes 1 million nets per year, we estimate that AMF's general costs will be about $0.33 per net.46 In total, we estimate that each LLIN purchased by AMF costs about $6.13 to purchase and deliver.

This estimate does not take into account costs of AMF's additional monitoring requirements. We do not have a good estimate of these costs.

Note that we prefer to include all costs incurred to carry out a project, not just those that the charity in question pays for itself. We believe that this gives the best view of what it costs to achieve a particular impact (such as saving a life), and also avoids the lack of clarity and complications of leverage in charity. Our estimate of the cost to distribute an AMF LLIN aims to both costs AMF pays and costs paid by others.

Cost per life saved

Using $6.13 as the total cost per net, we estimate the cost per child life saved through an AMF LLIN distribution at about $3,400.47

This does not include other potential benefits of LLINs (non-fatal cases of malaria prevented, prevention of deaths in age groups other than under-5 year olds, prevention of other mosquito-borne diseases, etc.). Full details at our report on mass distribution of LLINs.

As a general note on the limitations to this kind of cost-effectiveness analysis, we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

Room for more funds?

Since naming AMF as our #1 charity in late 2011, we have tracked over $10.6 million in donations made to it as a result of our recommendation. In that time, AMF has held the funds while attempting to negotiate a net distribution to spend them on. As of November 2013, it has not finalized a distribution large enough to spend the bulk of these funds48 (though it has funded a smaller-scale (~$1 million) distribution in Malawi49).

AMF’s past distributions have been relatively small in scale, compared to the types of distributions it is looking at as of November 2013. To find a sufficiently large distribution requires negotiating with the national malaria control programs of countries in sub-Saharan Africa, which we perceive to have some discretion in which funders they work with, and which we perceive to be choosing funders based on a variety of factors including size and reporting requirements. Because AMF is able to fund only a relatively small piece of a given country’s distribution, but has substantial reporting requirements, there may be fundamental reasons for governments to prefer other funders. We believe that this is the most important and fundamental explanation. We also believe that other factors may have also played a role. We discuss this topic in detail in this blog post.

As of November 2013, we do not plan to recommend more donations to AMF until and unless it commits the bulk of its current funds to net distributions.

AMF as an organization

We believe the Against Malaria Foundation to be an exceptionally strong and effective organization:

  • Track record: We feel AMF has built up a strong track record of raising money, finding smaller distribution partners, and getting partners to report information publicly at an unusual level, and verifiably getting bednets delivered. AMF is in the midst of attempting to implement its model at significantly larger-scale than it had before and has, thus far, failed in its attempts to do so over the past two years.
  • Communication: AMF has always communicated extremely clearly and directly with us and given thoughtful answers to our critical questions.
  • Self-evaluation: AMF has invested heavily in self-evaluation, going above and beyond what’s usual for data collection on bednet distributions: it has demonstrated a commitment to collecting long-term net usage data and malaria case rate data.
  • Transparency: AMF appears to value transparency as much as any organization we’ve encountered. It hasn’t just shared information with us; it publishes significant amounts of useful information publicly on its own, far more than the norm. We have never seen AMF hesitate to share information publicly (unless it had what we consider a good reason).

However, we see some potential room for improvement:

  • AMF does not seem to be as aggressive and ambitious about growth and capacity as it could be. It has operated for nine years and still has only two full-time staff members; it does not appear to us to have built as robust a fundraising operation as it could.
  • AMF has not conducted any field visits to distribution partners. We see this as a negative since we find such visits valuable.

More on how we think about evaluating organizations at our 2012 blog post.

Unresolved issues

Some of AMF's measures for collecting information on key questions are relatively new. We believe that AMF has a strong track record on ensuring that nets are delivered, and on general transparency, and we find its commitment to improving its documentation credible; but it does not have a robust track record on the answers to some key questions, particularly (a) whether individuals' needs for nets are accurately determined and (b) whether people use their nets properly over the long run.

As of November 2013, AMF has been unable to spend the majority of funds it has received due to GiveWell's recommendation.

Sources

Document Source
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Against Malaria Foundation Audited financial statement (2006) Source
Against Malaria Foundation Audited financial statement (2007) Source
Against Malaria Foundation Audited financial statement (2008) Source
Against Malaria Foundation Audited financial statement (2009) Source
Against Malaria Foundation Audited financial statement (2010) Source
Against Malaria Foundation Audited financial statement (2011) Source
Against Malaria Foundation Audited financial statement (2012) Source
Against Malaria Foundation Blog Source (archive)
Against Malaria Foundation Cape Verde summary: Rejected Source
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Against Malaria Foundation Distribution proposals: Fully funded examples (June 2010) Source
Against Malaria Foundation Distributions Source (archive)
Against Malaria Foundation DP151: MAG comments Source
Against Malaria Foundation DP171: MAG comments Source
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Against Malaria Foundation Future distributions Source (archive)
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Against Malaria Foundation LLIN distribution proposal form Source
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